I am finally able to share the results of the largest study to date evaluating treatment of young adults in the first hours after the onset of ischemic stroke! First, though, I would like to provide some background for you.
When I left practice in the community hospital setting in order to start at Duke University in June 2015, it was in part to have the resources to study stroke management in younger adults. I had questions. Lots of question.
- Are young adults receiving IV t-PA (the “clot-busting” drug for early ischemic stroke) with the same frequency as their older counterparts, or are they less likely to receive it because they are misdiagnosed?
- Stroke patients who are presented with the option of receiving IV t-PA early after a stroke are often told there is a 6% risk of bleeding from the drug, but is this accurate for younger adults? Or is the bleeding risk lower in younger, healthier individuals having strokes?
- Are there delays in treating younger adults because of a reluctance to treat, or delays in recognition that strokes are occurring?
In September 2015, I submitted a research proposal to the American Heart Association/American Stroke Association as part of an application for the “Young Investigator Award,” which would allow access to the largest stroke database in the United States, as well as funding for statistical analysis. I learned in January 2016 that the AHA/ASA agreed that these were questions worth answering, because the proposal was selected for the award. Over the course of the spring and summer of 2016 my colleagues and I worked on this project and getting the abstract ready for submission to the International Stroke Conference, and yesterday, the results were finally presented!
Overall, data on the strokes sustained by over 30,000 patients between the ages of 18 and 40 was analyzed, and compared with stroke data on 1.2 million strokes in patients over age 40. 12.5% of the younger patients received IV t-PA, versus 8.8% of patients over 40. Of patients who arrived at the hospital within 3.5 hours (more likely to be eligible for IV t-PA because they made it to the hospital within the time window to receive the drug), 68.7% of younger patients received t-PA, versus 63.3% of patients over 40.
The part of the study that excited me the most was the low rate of bleeding complications in the younger adult stroke patients – only 1.7% had symptomatic bleeding in the brain within 36 hours of t-PA, versus 4.5% of those over 40. Regarding severe bleeding elsewhere in the body, only 0.3% of younger patients experienced this problem, compared with 1.0% of those 40 and older. The reason this excites me is because we as neurologists finally know what the real bleeding complication rate is in the young adult population from t-PA, and instead of giving these young adults numbers that were generated from the more typical, older stroke population, we can say with good data to back us: “Your risk of bleeding from this drug is only 2%, and the likelihood of benefit far outweighs the potential risk.” Young people in the midst of a stroke deserve accurate data to consider when making the decision about whether to accept t-PA as a treatment.
We found significant delays both in getting the head CT scan done after arrival and in starting t-PA in the younger stroke patients. Adults over 40 who receive t-PA are more likely to receive it less than 60 minutes after arrival to the hospital, and are more likely to have their head CT scan done less than 25 minutes after arrival.
There is a lot of work to do in treating all stroke patients more rapidly, and we have to find ways to treat more patients overall when they present to the hospital in the midst of stroke. This is a step forward in understanding how younger adults with stroke are treated, and in comprehending the real complication rate, as opposed to giving them information that applies to the older population.
(Reference: Dodds JA, Xiao Y, Sheng S, Fonarow GC, Matsouaka R, Bhatti DL, Peterson E, Schwamm LH, Smith EE. Intravenous Recombinant Tissue-Type Plasminogen Activator Use in Young Adults with Acute Ischemic Stroke. AHA/ASA International Stroke Conference, Houston, TX – 23 February 2017.)